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Therapy
Rianto Setiabudy &
Dewi Selvina Rosdiana
Department of Pharmacology FMUI
Lecture for Infection and Immunology Module
April, 2012
1
Introduction (1)
The problems we are facing:
The ever increasing problem of bacterial
resistance (MRSA, VRE, ESBL producing
pathogens, MDR hospital pathogens)
Spread of infections in hospital setting
Cost of treatment
Inappropriate use of antimicrobial agents
2
Introduction (2)
Lack of new antimicrobial agents
developed in recent years
Unnecessary financial burden to the
patients
Scarcity of objective information on
appropriate use of antimicrobial agents
3
Outlines (1)
Pharmacological factors affecting
tissue penetration of antimicrobial
Selecting an appropriate antimicrobial
agent
Use of combinations
Prophylaxis
Duration of antimicrobial treatment
4
Outlines (2)
5
Pharmacologic factors affecting tissue
penetration of antimicrobials
clinical diagnosis
Educated guess or
Culture and sensitivity test
etiological diagnosis
7
Selecting an antimicrobial agent (contd)
determine the drug of choice
If in appropriate give a second-
line drug. Consider: safety,
efficacy, suitability, and cost
9
Tips for selecting an appripriate
antimicrobial agent (2)
A new generation antibiotic is not always
superior to its older generations
A slightly more potent antibiotic shown in
vitro, is not necessarily associated with better
clinical efficacy
10
Use of antimicrobial combinations
(1)
Indications:
Empirical therapy of severe infections in
which cause is unknown
Treatment of polymicrobial infections
Enhancement of antimicrobial activity in
treatment of specific infections
Prevention of emergence of resistance
11
Use of antimicrobial combinations
(2)
12
Use of antimicrobial combinations
(3)
Disadvantages of AM combinations:
Increased risk of toxicity
Selection of multiple-drug-resistant
microorganisms
Increased cost
Possibility of unexpected antagonistic
effect
13
Use of antimicrobial combinations
(4)
14
Prophylaxis
Characteristics of successful prophylaxis:
Aimed at a specific pathogen
The pathogen is highly sensitive to the
prophylactic agent used
Characteristics of unsuccessful
prophylaxis:
Aimed at any or all microorganism in the
environment of a patient
(Chambers, 2001)
15
Duration of therapy (1)
Determined by:
The ability of the pathogens to resist
hosts defense mechanism
Physical location of the pathogen
Potency of the AM agent
The frequency of development of
resistance
16
Duration of therapy (2)
Examples:
Acute uncomplicated cystitis: one dose 3
days
Acute gonococcal urethritis: one dose
Pneumococcal pneumonia: until afebrile 3
days, at least 5 days
Bacterial endocarditis: 4 weeks
Streptococcal pharyngitis: 10 days
Pulmonary tuberculosis: 6 months
Extra pulmonary tuberculosis: 12-24 months
17
Factors causing failure of treatment (1)
19
Time-kill curves of P. aeruginosa
with exposure to tobramycin
Log CFU/ml
Time (h)
(Craig, 1991)
20
Patterns of antibiotic killing activity
(1)
Pattern 1: concentration-dependent
killing
E.g.: aminoglycosides,
fluoroquinolones
Strategy of dosing regimen:
maximize concentrations
Parameters determining efficacy:
ratios of Cmax/MIC or AUC/MIC
(Deziel-Evans, 1986)
21
Time-kill curves of P. aeruginosa with
exposure to ticarcillin
Log CFU/ml
Time (h)
(Craig, 1991)
22
Patterns of antibiotic killing activity
(2)
MIC
Time
Time above-MIC 25
Penetration of antimicrobials into
cerebrospinal fluid (1)
Excellent:
Trimethoprim
Sulfonamides
Chloramphenicol
INH
Rifampicin
Flucytocin
26
Penetration of antimicrobials into
cerebrospinal fluid (2)
27
Penetration of antimicrobials into
cerebrospinal fluid (3)
Ceftriaxone
Ceftazidime
Aztreonam
Imipenem
Fluoroquinolones
28
Penetration of antimicrobials into
cerebrospinal fluid (4)
Poor penetration:
Aminoglycosides
First generation cephalosporins
Clindamycin
Vancomycin
Cefoxitin
29
Factors responsible for treatment
failure (1)
Poor antimicrobial activity
Active antimicrobial agent fails to be
delivered to the site of infection in
sufficient concentration
Inaccessible site of infection
Inadequate host body defenses
Treatment duration is too short to
prevent relapse
30
Factors responsible for treatment
failure (2)
31
THANK YOU
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